Healthcare Provider Details

I. General information

NPI: 1306504857
Provider Name (Legal Business Name): CALIFORNIA SENSORY AND DEVELOPMENT GYM L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 12/01/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N EMILY ST
ANAHEIM CA
92805-1910
US

IV. Provider business mailing address

905 N EMILY ST
ANAHEIM CA
92805-1910
US

V. Phone/Fax

Practice location:
  • Phone: 845-300-0693
  • Fax:
Mailing address:
  • Phone: 845-300-0693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: LADYBIRD MANANGAN REYES
Title or Position: MANAGER/OWNER
Credential: PT
Phone: 845-300-0693